Category: Stones: PCNL
VS2-8 - Supine PCNL in a horseshoe kidney.
Introduction & Objective :
We present a case of supine percutaneous nephrolithotomy in a horseshoe kidney.
A 62-year-old male with no medical history came to our clinic due to a lithiasis in left kidney. X-ray was performed, showing a 2 cm stone in the left half kidney. CT showed a 23 mm x 16 mm lithiasis of 1065 HU. Excretory phase can show the best percutaneous path to plan the surgery.
Methods :
Galdakao position was used to perform the PCNL. This position can help us to do an endoscopic combined surgery. In this position is possible to use a ureteral stent to inject contrast material to a better view on the x-ray. Regarding the images, we used the middle calyx to perform the puncture. We had to increase the angle to better view the posterior calyx.
Percutaneous access needle with echogenic tip was used, it was guided ultrasonography and radiologically through the middle calyx. First, we performed a progressive dilatation with fascial dilators and then we used a balloon, prior passage of safety guide through a double light catheter. A 24 F Amplatz type renal sheath was used.
We are used to apply ballistic energy in the PCNL surgery, to get a faster and better stone fragmentation. Also to remove stones we are used to take tweezers. They are more economical and can catch bigger stones. When stones´ si ze is too big we can change their position or try to rotate the tweezers to remove them.
A ureteral catheter can get lower pressure in the kidney, allowing higher flow and a better view. Even in Galdakao position we can move the stent perfectly.
Finally, we used a flexible cystoscope to review all the calyx.
To conclude the surgery, we placed a ureteral catheter under vision. It was removed in 2 weeks.
Results :
The stone had an intermediate hardness, and according to HU it seemed to be an oxalate calcium dihydrate lithiasis, which was confirmed in the analysis. Stone composition was 70% oxalate calcium dihydrate and 30% calcium phosphate, no bacteria grown in the stone and the urine culture.
No stones were observed in the X-ray and the echography
Conclusions :
According to our results supine PCNL is a safety procedure in a horse shoekidney. We have to take care about anatomy and perform always a CT of the kidney and the surrounding structures to provide information regarding interpositioned organs.
Javier Perez-Ardavin
– Resident fith year, Hospital Universitari i Politècnic La Fe, Valencia, Comunidad Valenciana, Spain- JS
José Vicente Sánchez-González
– Resident fith year, Hospital Universitari i Politècnic La Fe, Valencia, Comunidad Valenciana, Spain - PB
Pilar Bahílo Mateu
– Resident fith year, Hospital Universitari i Politècnic La Fe, Valencia, Comunidad Valenciana, Spain - MT
Marta Trassierra
– Hospital Universitari i Politècnic La Fe, Valencia, Comunidad Valenciana, Spain - DO
Domingo de Ordaz Jurado
– Hospital Universitari i Politècnic La Fe, Valencia, Comunidad Valenciana, Spain - JL
Jose Daniel López-Acón
– Hospital Universitari i Politècnic La Fe, Valencia, Comunidad Valenciana, Spain - AB
Alberto Budia Alba
– Hospital Universitari i Politècnic La Fe, Valencia, Comunidad Valenciana, Spain - FB
Francisco Boronat Tormo
– Hospital Universitari i Politècnic La Fe, Valencia, Comunidad Valenciana, Spain